Vendor Electronic Funds Transfer (EFT) Registration Request Form
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SSA/RCC-13-001-S Attachment E State of Maryland Comptroller of Maryland
Vendor Electronic Funds Transfer (EFT) Registration Request Form
Date of request ______
Business identification information (Address to be used in case of default to check):
Business/Individual name______
Address line 1______
Address line 2______City ______State ______Zip code
Taxpayer identification number: Federal Employer Identification Number: (or) Social Security Number:
Business contact name, title, e-mail and phone number including area code. (And address if different from above). ______
______
Financial institution information:
Name and address ______
______
Contact name and phone number (include area code) ______
______
ABA number
Account number
Account type: Checking Money Market Savings
Format Desired: ______CCD+ ______CTX* ______EDI* (Check one) *Note – There may be a charge to you by your bank with this format. You must contact your bank to receive this format.
A VOIDED CHECK from the bank account must be attached or letter from the bank confirming the account number.
COT/GAD X-10 1 Transaction requested:
1. Initiate all disbursements via EFT to the above account.
2. Discontinue disbursements via EFT, effective ______
3. Change the bank account to above information – a copy of the approved Registration Form for the previous bank account must be attached
I am authorized by *______(hereinafter Company) to make the representations contained in this paragraph. Company authorizes the Comptroller and the Treasurer of Maryland to register it for electronic funds transfer (EFT) using the information contained in this registration form. Company agrees to receive all funds from the State of Maryland by electronic funds transfer according to the terms of the EFT program. Company agrees to return to the State of Maryland any EFT payment incorrectly disbursed by the State of Maryland to the Company’s account. Company agrees to hold harmless the State of Maryland and its agencies and departments for any delays or errors caused by inaccurate or outdated registration information or by the financial institution listed above.
*Name of registering business entity
______Signature of individual, company treasurer, controller, or chief financial officer and date
Completed by GAD/STO
Date Received ______
GAD registration information verified ______Date to STO______
STO registration information verified ______Date to GAD______
R*STARS Vendor No. and Mail Code Assigned:
______
______State Treasurer’s Office Approval Date General Accounting Division Approval Date
To Requestor:
Please retain a copy of this form for your records. Please allow approximately 30 days from the date of your request for the Comptroller’s and Treasurer’s Offices to process your request. Failure to maintain current information with this office could result in errors in payment processing. If you have any questions, please call the EFT registration desk at 410-260-7375.
Please submit form to: EFT Registration, General Accounting Division Room 205, P.O. Box 746 Annapolis, Maryland 21404-0746 (or) Fax: 410-974-2309
Instructions: Obtain Electronic Funds Transfer instructions at http://compnet.comp.state.md.us/gad. Questions may be submitted by email to: [email protected]. Or call 1-888-784-0144
COT /GAD X 10